Job Summary:
The Quality Analyst supports the system’s quality, patient safety, regulatory compliance, and performance improvement activities through accurate data collection, analysis reporting, auditing, and follow-up. The position works collaboratively with nursing, clinical departments, hospital leadership, and other stakeholders to identify trends, monitor quality indicators, and support improvement initiatives.
The Quality Analyst assists with maintaining regulatory readiness, tracking corrective action plans, preparing quality reports, and supporting committees and departmental performance improvement activities. The role requires attention to detail, sound judgment, effective communication, confidentiality, and the ability to organize multiple priorities while meeting established deadlines. The ideal candidate is a critical thinker, innovative, team-oriented, self-motivated, and accountable, with a commitment to excellence in healthcare delivery and employee wellness.
Qualified Candidate:
Educational and Certification Requirements
- Associates degree or higher in healthcare related field; or a specialty area for healthcare quality
- Experience: At least 3-5 years of experience in a hospital quality role.
- Skills: Strong leadership, communication, and organizational skills; ability to handle high-stress situations effectively.
- Must have and maintain certifications as follows: Certifications in quality equivalent to the Certified Professional in Healthcare Quality (CPHQ), Health Care Quality and Management (HCQM), Certified Professional in Quality and Patient Safety (CPQPS), and Six Sigma.
Essential Skills:
- Data collection, validation, analysis, and reporting
- Quality improvement and patient safety principles
- Problem solving and interdisciplinary collaboration
- Strong oral and written communication skills
- Organization, prioritization, and attention to detail
- Ability to interpret policies, standards, and regulatory requirements
- Ability to support evidence-based practice and performance improvement
- Confidentiality and professional judgment
- Familiarity with healthcare software and reporting technologies
- Working knowledge of healthcare facility laws, regulations, accreditation standards
Reports to: Director of Nurses (DON)/Chief Nursing Officer (CNO)
Responsibilities:
· Quality & Performance Improvement:
o Collect, validate, monitor, and analyze quality indicators, performance metrics, patient safety data, and patient satisfaction information.
o Prepare routine and ad hoc reports, dashboards, summaries, and presentations for leadership, committees, and departments.
o Assist departments with performance improvement projects, action plans, and measurement of outcomes.
o Identify trends, variances, and opportunities for improvement and communicate findings to the appropriate leader.
o Support quality and patient safety committees by preparing data, reports, minutes, follow-up items, and other requested materials.
· Regulatory Readiness & Compliance:
o Assist with ongoing readiness for accreditation and other applicable regulatory surveys.
o Conduct or support audits and tracers to evaluate compliance with policies, standards, and regulatory requirements.
o Maintain organized documentation for surveys, audits, corrective action plans, and performance improvement activities.
o Track assigned corrective actions and follow up with responsible departments regarding completion and supporting evidence.
o Assist with preparation and submission of required quality data and reports within established deadlines.
· Patient Safety & Event Review:
o Support the collection, review, trending, and reporting of patient safety events, complaints, and other quality-related occurrences.
o Assist with investigations, root cause analyses, failure mode reviews, and corrective action activities as directed.
o Monitor follow-up actions and help evaluate whether implemented changes are sustained and effective.
o Maintain confidentiality and appropriate handling of quality, peer review, and patient information in accordance with hospital policy and applicable law.
· Operational & Data Management:
o Maintain accurate quality databases, logs, spreadsheets, files, and supporting documentation.
o Verify data accuracy and completeness before submission or presentation.
o Assist in developing standardized tools and workflows that improve the efficiency and reliability of quality reporting.
o Meet established reporting timelines and communicate barriers or data integrity concerns promptly.
o Perform other quality, compliance, patient safety, or performance improvement duties as assigned.
Structured Pillars:
1. Quality & Patient Safety
- Quality Monitoring: Collect, validate, analyze, and report quality and patient safety data.
- Performance Improvement: Support improvement projects and evaluate progress toward established goals.
- Patient Safety: Assist with event review, trend identification, follow-up, and corrective action tracking.
2. Regulatory Compliance & Readiness
- Regulatory Readiness: Support continuous readiness for surveys, inspections, and audits.
- Auditing: Conduct assigned audits and tracers and report findings accurately.
- Corrective Actions: Track action plans, deadlines, and evidence of sustained compliance.
3. Data Analysis & Operational Efficiency
- Data Integrity: Maintain accurate, complete, and timely quality data.
- Reporting: Develop routine reports, dashboards, and summaries for decision-making.
- Workflow Improvement: Identify opportunities to improve quality reporting and departmental processes.
4. Collaboration & Communication
- Department Support: Work collaboratively with clinical and non-clinical departments on quality initiatives.
- Committee Support: Prepare data and materials and assist with follow-up for quality-related committees.
- Communication: Present findings clearly and escalate significant concerns through the appropriate chain of command.
5. Professional Accountability & Safety
- Accountability: Complete assigned responsibilities accurately, timely, and in accordance with hospital expectations.
- Confidentiality: Protect patient, employee, quality, and peer review information.
- Safety: Support hospital safety initiatives and promote a culture of reporting, learning, and continuous improvement.
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Work Location: In person
